Saturday, December 9, 2006

IV

Dispatched for the "unknown," and updated as "man not breathing" we raced to the address.

Down the darkened highway and over the Connecticut river, I was calm and collected. I thought about what laryngoscope blade I would use. A miller this time, perhaps. I used a mac on the last call and that went well, but I want to try as many different ways as possible. My partner and I joked about the possibility of arriving on scene and finding our "man not breathing" standing outside his house, waving to us. It would be awful, we thought, if after all this he turned out to be actually breathing.

An ambulance was already on scene when we got there, and as I walked towards the house the patient was already on his way out. 3 EMTs were pushing the stretcher quickly, a frantic look on their faces. One of them was bagging the patient, another holding the O2 tank. A third was pushing the stretcher quickly towards the ambulance.

"Does he have a pluse?" I shouted to them, immediately feeling stupid. Of course he has a pulse, nobody was doing CPR. They affirm that he does, and tell us the rest of the story: "22 year old male found on the floor by his girlfriend who says he was barely breathing and gurgling. We found him breathing at a rate of 4 per minute and started bagging. Dont have an airway yet. Girlfriend says he has a history of ETOH abuse but nothing narcotic." I thank them, and jump into the back of the ambulance.

I'm a little less calm now. The urgency of the EMTs has rubbed off on me a little bit, and I feel my heart start to pick up pace. I set the monitor on the bench seat and open up the big ALS bag. I try to prioritize my actions. First thing we need to do is get an airway, I think. An OPA should do for now. Next is monitor, IV, and drugs. I'm hoping this is another overdose that will wake up with narcan.

The patient is rolled into the back of the ambulance and when within reach, I look at the pupils. I am hoping for pinpoint, but what I see is only moderate constriction-- if at all. I wish that these things would be more definite. Constriction should be obvious, normal presentation should be universal. I am stuck with an assessment that serves only to produce more questions rather than answer them. Maybe opiates, maybe not.

I refocus, opening the patient's mouth and inserting an OPA as I direct an EMT to continue bagging. The monitor goes on and I see a rate of 110, in sequence with a pulse that I check at the carotid artery. O2 saturation is in the high 90's, lung sounds clear and equal with bagging. Good.

Time for the IV. I get a hold of the patient's arm and move it so that I have full access to the underside. I strap on a tourniquet and to my dismay, nothing pops up. No obvious veins. I rub my gloved hand up and down the forearm, pressing lightly over the AC space. Nothing. I begin to sweat as I pull my gloves on tighter. Maybe I'll feel something if it weren’t for these damn gloves. My partner, seeing my difficulty, looks over my shoulder. "Right there," he says, pointing to a spot on the forearm. "See it there?" I dont. I feel over the spot, it feels vaguely spongy but nothing to get excited about. I confirm again where he was pointing, my voice trailing off as I admit that I cant see it. "Go for it," he says, "its right there." He hands me a 20 gauge needle and I stick the patient's arm at the spot where I was told. No flash in the catheter. I'm not in. I move the needle slowly from right to left, feeling with my other fingers as I go. I cant see anything, cant feel anything. I am fumbling in the dark.

I try again with a different needle in a different spot. Again, no flash. I slowly fan the needle from left to right, hoping. I can feel everyone watching me. My partner, the two EMTs in the back of the ambulance, the frantic girlfriend in the front seat looking back. "I'm not finding this vein," I admit to my partner. I suggest that we go with nasal narcan for now. He agrees. I cant tell if he is disappointed or upset with me. He must be. He saw the vein, I didnt. I cant even get a flash. Another failed attempt. This patient needs an IV, and I cant do it.

I look up from the arm, and notice that my partner already has the narcan drawn up with the nasal spray attachment ready. The intubation equipment is out and assembled, ready. The patient has his clothes removed, and a rapid trauma assessment is already done. A blood glucose has been measured, coming up as normal at 124. ...All things that I should have done had I not been struggling with this damn IV. We're already halfway to the hospital and I've got nothing done. I am overwhelmed with the amount of work yet to do, and the incredibly short time I have left to do it.

I move the tourniquet down to the forearm as my partner sprays the nasal narcan. I think I see a small vein in the back of the hand so I wipe with alcohol, take out another needle, and dive in. No flash again. I press the needle all of the way in, desperate to get this vein. I move slowly, gritting my teeth as the pressure of necessity continues to climb. I move the needle one more time, and there it is. The flash chamber fills up with blood. I let out my breath, not knowing that I was holding it. The catheter slides neatly into the vein. "Ive got the line" I say, exhausted. There is no hint of victory in my voice.

By the time the IV is secured down and I have composed myself, the patient is beginning to wake up. He is confused and slightly agitated, asking where he is, who we are, what is going on. The girlfriend in the front of the ambulance lets out a "oh thank god" and begins yelling back at her boyfriend. "Are you okay honey? You scared the shit out of us! You werent breathing!"

I wipe the sweat away from my forehead and take my jacket off. When the hell did it get so hot back here, I think. I feel like a complete mess. There are angiocath wrappers all over the floor, failed IV sharps strewn about. The IV kit is completely destroyed from me rummaging through with one hand as I fumbled with the IV attempts.

I look back at the patient and try to find a reason for this mess that I've made. I spent almost my entire time with this patient trying to get a single IV. It becomes clear to me that all that mattered to the patient: the ventilations, the narcan, the complete assessment and transport, were performed by everyone else other than me. EMTs and my paramedic preceptor were working furiously around me the entire time securing the necessities, while I sat to the side holding the patients arm and played with the needles. My influence on this patient's outcome was zero.

I need to learn to better prioritize. I need to find a better way to get everything done in a timely fashion. I need to learn how to not depend so much on everyone else around me. Sometime in the near future, I will be expected to be autonomous. I will be the only caretaker in the back of the ambulance, left with no EMT to delegate duties to, no preceptor to watch my back.

I am sobered. There is still so much left to learn.

3 comments:

Shane said...

While calls like that can be frustrating, your priorities will be straight in time. Ride time while in school is the time for you to focus on something during each call you do. You're not expected to run a call like your preceptor would or like another experienced medic. If you can learn something from each single call that you do that will effect your practice further into your career, then the call really didn't go bad. This call you learned about priorities, delegation and most importantly self direction. You're in a good spot to take a lot of this call that will bring about a positive effect on the patients you treat in the future. Strong work in my opinion. Keep your head up and most importantly continue to learn and refine your practice. Years from now you'll be an experienced paramedic passing knowledge to the newest group of students.

Anonymous said...

First of all I have to ask - Where did you learn to write? The Foster Adams I know can barely speak.

Just Kiddin.

The writing is awesome. You paint an amazingly detailed account of events and emotions. I feel "at" the call. Strong work.

As for what you feel was a 'bad" call. Trust me, we have all been there. And between me and you (if you are NOT Foster - please skip to the next paragraph) I still, on occasion, tunnel in on one skill that I'm getting tripped up on and I fail to complete a multidude of other necessary tasks. We all (even Super Shane) fuck up at times. Learn from them.

Just remember to keep a little 'Snooze Alarm' in the back of you head. Before you hit the button for 'a few more minutes / just one more try'; remember, it not about YOU, it's about the PATIENT.

It take a strong man to admit he's not perfect. Move on for the betterment of your patient.

If you do a full assessment on each patient and perform your skills to the best of your abilities on each call - no one can fault you.

The BEST Medics are always looking for what they could have done better on "that" call. The rest of the medics are those who believe the call went perfect.

Stay Safe -
Pedi Code Partner

Brett said...

Shit happens... the key is to learn from it... which it sounds like your doing